Download Secondhand Smoke Exposure in Public Places in Guatemala

2730
Secondhand Smoke Exposure in Public Places in
Guatemala: Comparison with other Latin
American Countries
Joaquin Barnoya,1,2 Carlos Mendoza-Montano,3 and Ana Navas-Acien4
1
Department of Pediatrics, Unidad de Cirugı́a Cardiovascular de Guatemala; 2Department of Epidemiology, University of California,
San Francisco; 3Asociación Para la Prevención de la Enfermedad Cardiovascular, Guatemala City, Guatemala; and
4
Department of Environmental Health Sciences and Institute for Global Tobacco Control,
Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
Abstract
Objective: To measure secondhand smoke levels in
workplaces in Guatemala and to compare exposure to
levels in other Latin American cities.
Methods: Exposure was estimated by passive sampling
of vapor phase nicotine using a filter badge. Filters
were placed in 1 hospital, 1 school, 2 universities,
1 government building, the airport, and 10 restaurants/
bars. In total, 103 filters were deployed (plus
7 duplicates and 10 blanks). Nicotine (Mg/m3) was
measured by gas chromatography. Medians [interquartile ranges (IQR)] of nicotine concentrations were
reported and compared with other Latin American
cities. A survey about attitudes for smoke-free workplaces was distributed among employees.
Results: Nicotine was detected in most (68%) locations
surveyed (including workplaces where smoking is
banned). The highest levels were found in bars [median,
4.58 Mg/m3 (IQR, 1.71-6.44)] and restaurants [median, 0.56
Mg/m3 (IQR, 0.46-0.71)]. Nicotine concentrations in bars
and restaurants were 710 and 114 times higher, respectively, compared with hospital concentrations after
adjustment for smoking ban signs, type of ventilation,
and volume of the area. Support for smoke-free environments was high, except in bar/restaurant and airport
workers. Airborne nicotine levels in Guatemala were
similar to those found in other Latin American cities.
Conclusion: In Guatemala, exposure to secondhand
smoke is highly prevalent. Workers in bars and
restaurants are disproportionately exposed to secondhand smoke compared with other workers. There is an
urgent need for complete smoke-free legislation and for
educating workers about the benefits of smoke-free
workplaces. (Cancer Epidemiol Biomarkers Prev
2007;16(12):2730 – 5)
Introduction
Secondhand smoke (SHS), the mixture of mainstream
and sidestream tobacco smoke, harms children and
adults’ health (1). Involuntary exposure to SHS occurs
in places where active smoking takes place. The solution
to SHS is simple and straightforward: smoke-free
environments. In a recent study in selected cities of
Latin America, however, exposure to SHS was common
in most public places (2). Air nicotine concentrations
were highest in bars and restaurants. In restaurants,
tobacco smoke was also found in nonsmoking areas
adjacent to smoking areas. Finally, tobacco smoke was
detected in most hospitals and secondary schools
surveyed (2).
On February 27, 2005 the WHO Framework Convention on Tobacco Control encouraged countries to
Received 3/21/07; revised 8/25/07; accepted 10/3/07.
Grant support: Research for International Tobacco Control of the International
Development Research Centre, Ottawa, Canada, and the financial support of the
Canadian Tobacco Control Research Initiative, the American Cancer Society, and
Cancer Research, UK. Ana Navas-Acien was supported by the Flight Attendant
Medical Research Institute.
The costs of publication of this article were defrayed in part by the payment of page
charges. This article must therefore be hereby marked advertisement in accordance
with 18 U.S.C. Section 1734 solely to indicate this fact.
Requests for reprints: Joaquin Barnoya, 6a Av 8-71 zona 10, Clinica no. 3 Ala Sur,
Guatemala City 01010, Guatemala. Phone: 502-5993-2369; Fax: 502-2369-4443.
Email: [email protected]
Copyright D 2007 American Association for Cancer Research.
doi:10.1158/1055-9965.EPI-07-0229
‘‘Protect citizens from exposure to tobacco smoke in
workplaces, public transport and indoor public places.’’
Creating smoke-free environments has been shown to
lead to significant decreases in heart disease and lung
cancer mortality, smoking prevalence, and cigarette
consumption (1, 3-5). For heart disease, although SHS
increases the risk by 30%, recent evidence indicates that
smoke-free environments have immediate cardiovascular benefit, decreasing heart attack admissions to the
hospital and heart disease incidence rates (6-9). In
addition, pulmonary function, respiratory symptoms,
and inflammatory markers also decrease after smoke-free
environments are implemented (10).
Guatemala signed the Framework Convention on
Tobacco Control and ratified it in November 16, 2005.
Guatemalan Law states that smoking is banned in healthcare and educational facilities, and public transportation
(buses, taxis, and trains; ref. 11). In government and
private work sites, restaurants, and other public places,
the law states that smoking is restricted (allowed in
designated areas). No ban or restriction of smoking is
stated in bars (11). Currently, the tobacco industry
Courtesy of Choice program, endorsing ventilation and
accommodation as a solution to SHS exposure is well
established in the country.5 Yet, there is hope for
5
http://legacy.library.ucsf.edu/tid/fbg19c00
Cancer Epidemiol Biomarkers Prev 2007;16(12). December 2007
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Cancer Epidemiology, Biomarkers & Prevention
Table 1. Number of samples and airborne nicotine
concentrations (Mg/m3) in selected sites in Guatemala
City
Institution
Hospital
School
University
Government building
Airport
Restaurant
Bar
Analyzed
samples
(N = 89)
Lost/
damaged
samples
(N = 14)
Samples
in which
nicotine was
detected (%)
20
4
24
11
10
10
10
3
2
1
3
4
0
1
50
0
62
73
73
91
100
Guatemala to create smoke-free environments in all
indoor public places including restaurants and bars. As
of October 2007, Law 3309, which mandates 100% smokefree environments in Guatemala, has been approved by
the Congress’s Health Commission and is still pending
discussion in Congress for its approval. If the law were
finally approved, Guatemala could become the second
100% smoke-free country in Latin America, after Uruguay, and the first country in Central America.
Given the outlined situation in Guatemala, determining levels of exposure to SHS in public places is vital to
support the final approval of the smoke-free legislation
and to effectively endorse and monitor the creation of
smoke-free environments. The objective of this study was
to determine levels of nicotine (as a measure of SHS
exposure) in indoor public places and workplaces in
Guatemala City, to be used as a tool to support the
approval, implementation, and enforcement of Law 3309.
In addition, we sought to compare levels of exposure to
SHS in public places in Guatemala with levels of SHS
exposure in other Latin American countries, using a
common protocol.
Materials and Methods
This is a cross-sectional SHS exposure survey measuring
environmental nicotine concentrations in selected public
places and workplaces in Guatemala City. We followed
the same methodology used by Navas-Acien et al. (2) in
other Latin American cities. Public places included one
tertiary hospital, one school in a low-middle class
neighborhood, one city government building, two universities (one public and one private), the international
airport, and restaurants and bars (Table 1). The workplaces selected were chosen given their relevance to be
included in any comprehensive smoke-free law. The
hospital, school, universities, and government building
were selected on a convenience sample strategy and were
similar to other health, education, and government
facilities in Guatemala. To select restaurants and bars,
we walked through two of the most popular towns in
Guatemala City and asked for permission to place the
monitors. Restaurant owners and managers were willing
to collaborate and only three declined participation.
Permission to place sampling devices was obtained from
the responsible authorities at each site. The study was
approved by the institutional review boards of the
Roosevelt Hospital in Guatemala City, Guatemala and
the Johns Hopkins Bloomberg School of Public Health,
Baltimore, MD.
Sampling locations in each site were selected on a
convenience basis, without knowledge of the extent of
smoking taking place in each site, to represent areas
where people frequently work or spend time. Sampling
locations included physicians’ rooms, nurses’ rooms,
patients’ areas, cafeterias, and administrative offices in
hospitals; teachers’ rooms, hallways, stairways, students’
bathrooms, and administrative offices in schools and
universities; waiting rooms, administrative offices, hallways, and stairways in the government building; ticketing offices, boarding gates, duty-free shops, hallways,
and baggage claim in the airport; and smoking and
nonsmoking sections in restaurants and bars. Of 103
location samples, the sampling devices were lost or
stolen in 14 (14%) sites leaving 89 for analysis. Losses
most frequently occurred in the school (2, 33%) and the
airport (4, 29%).
Several methods could be used to ascertain exposure
to SHS, depending on the objective of the study. To
track the effects of clean indoor air and policies (or the
lack of thereof), the quantification of one or more
tracers of SHS in the environment are critical. Nicotine
is an attractive tracer of indoor air pollution and the
methods used to measure it are relatively simple,
accurate, and inexpensive. Vapor phase nicotine is a
widely used tracer for SHS particulate matter and SHS
as a whole (1, 12). In this study, the time-weighted
average concentration of SHS was estimated by passive
sampling of vapor phase nicotine using a filter badge
treated with sodium bisulfate (13). Sampling devices
were left in each location for 7 working days. The
collected nicotine was extracted from the filter and
analyzed at the Center for Urban Environmental
Health at the Johns Hopkins Bloomberg School of
Public Health via gas chromatography with nitrogenselective detection. The concentration of nicotine is
given in micrograms (Ag) per effective volume of air
sampled (m3). For quality control, we placed a total of
seven additional duplicate sampling devices. The
intraclass correlation coefficient between log-transformed nicotine concentrations of duplicate samples
was 0.97. We also placed 10 additional blank sampling
devices used to calculate the nicotine detection limit
(0.0014 Ag/m3) and to determine blank-corrected
nicotine concentrations. Thirty-two samples had nicotine
concentrations below the detection limit (0.0014 Ag/m3);
11 in the hospital, 4 in the school, 10 in the universities,
3 in the government building, 3 in the airport, 1 in the
restaurants, and 0 in the bars. For consistency with
previous reports in Latin America, we assigned a value
of one half of the detection limit to samples that were
below the detection limit (2).
Medians and interquartile ranges (IQR) were used to
describe the data, and a box plot was used to graphically
present the distribution of nicotine concentration for each
institution and by location characteristics including the
presence of smoking signs, type of ventilation, and
volume of the area. To compare nicotine concentrations
across institutions and by other location characteristics,
we computed crude and multivariable adjusted ratios of
the geometric mean of nicotine concentrations and its
95% confidence interval versus the reference category
Cancer Epidemiol Biomarkers Prev 2007;16(12). December 2007
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Secondhand Smoke Exposure in Public Places in Guatemala
Table 2. Airborne nicotine concentrations (Mg/m3) by location characteristics
Institution
Hospital
School/University
Government building
Airport
Restaurant
Bar
Smoking ban sign
Yes
No
Ventilation
Natural
Mechanical
Mixed
Volume (m3)
<100
100-500
z500
N
Median
GM
IQR
Crude ratio of GM
(95% confidence interval)
Adjusted ratio* of GM
(95% confidence interval)
20
28
11
10
10
10
<LD
0.01
0.01
0.01
0.58
4.58
0.004
0.005
0.01
0.01
0.56
3.02
<LD-0.01
<LD-0.02
<LD-0.05
<LD-0.01
0.46-0.71
1.71-6.45
1.00 (reference)
1.21 (0.49-3.01)
2.23 (0.70-7.17)
1.41 (0.42-4.68)
131 (39.3-436)
701 (210-2333)
1.00 (reference)
0.88 (0.33-2.37)
1.56 (0.28-8.73)
0.94 (0.23-3.77)
114 (32.1-400)
710 (206-2442)
23
66
0.01
0.01
0.01
0.02
<LD-0.05
<LD-0.38
1.00 (reference)
1.68 (0.46-6.19)
1.00 (reference)
0.87 (0.34-2.18)
56
17
16
0.01
0.01
0.01
0.03
0.01
0.01
<LD-0.41
<LD-0.05
<LD-0.06
1.00 (reference)
0.59 (0.13-2.68)
0.36 (0.08-1.73)
1.00 (reference)
1.04 (0.25-3.95)
1.86 (0.63-5.48)
28
37
24
0.02
0.01
0.02
0.01
0.02
0.03
0.01-0.31
<LD-0.33
0.01-0.31
1.00 (reference)
1.42 (0.36-5.61)
2.81 (0.61-12.9)
1.00 (reference)
0.56 (0.24-1.34)
1.46 (0.54-3.93)
Abbreviations: GM, geometric mean; LD, limit of detection.
*Adjusted for type of public place, presence of a smoking ban sign, type of ventilation or volume of the area.
using linear regression models on log-transformed
nicotine. Analyses were done using Stata version 7.0
(Stata Corp.).
At the end of the air nicotine sampling, all workers
who occupied the places that had been monitored were
invited to complete a short questionnaire about attitudes
for smoke-free environments and perception of exposure
to SHS [adapted from Stillman et al. (14)]. The questionnaires were distributed at the moment the sampling
devices were removed. A total of 137 workers completed
the survey and no worker refused to complete the
questionnaire.
Results
Nicotine Concentrations in Public Places. Airborne
nicotine was detected in most locations surveyed (68%),
ranging from 0% in the school to 95% in bars/
restaurants. Nicotine concentrations were higher in
bars/restaurants and lower in the school (Table 2;
Fig. 1). In the government building and the airport,
nicotine concentrations were generally low, yet it was
found in most sampling sites (73% in both places). The
highest nicotine concentration was found in a bar,
8.86 Ag/m3. In bars and restaurants, nicotine concentrations in nonsmoking areas [median, 0.77 Ag/m3 (IQR,
0.44-4.18)] indicated that tobacco smoke was present at
concentrations just slightly lower than nicotine concentrations in corresponding smoking areas [median,
0.99 Ag/m3 (IQR, 0.46-5.58)]. Nicotine concentrations in
restaurants and bars were 114 and 710 times higher,
respectively, compared with hospital concentrations
after adjustment for the presence of smoking ban sign,
type of ventilation, or volume of the indoor area
sampled (Table 2).
Compared with other Latin American cities, nicotine
concentrations in Guatemala were similar for most sites
(Table 3; ref. 2). In Latin American cities, low nicotine
concentrations were found in hospitals, schools, and
government buildings (except in Argentina and
Uruguay). Nicotine concentrations were generally higher
in airports (Guatemala airport yielded the lowest level).
Consistently for all cities, the highest levels were found
in restaurants and bars. Nicotine concentrations found in
bars in Guatemala [4.58 Ag/m3 (IQR, 1.71-6.44)] were
among the highest in the region.
Workers’ Perceptions. The mean age of the questionnaire respondents was 31 (SD, 11.46) years and 49%
were male. Twelve percent (23% male and 1% female)
classified themselves as current smokers and an additional 16% as occasional smokers. The prevalence of
current smoking was highest in bar/restaurant workers
and lowest in hospital workers, 25% and 4%, respectively. Most hospital and school/university workers
agreed that workplaces should be smoke-free, 75% and
65%, respectively (Table 4). Agreement was lower in
government building (50%), airport (39%), and bar/
restaurant workers (30%). The percentages of agreement
with smoke-free environments were similar when workers were asked specifically if their institution should be
Figure 1. Concentrations of airborne nicotine in public places
in Guatemala City, 2006. Horizontal lines within boxes,
medians; boxes, IQR; bars, values within 1.5 times the IQR;
solid circles, outlying data points.
Cancer Epidemiol Biomarkers Prev 2007;16(12). December 2007
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Cancer Epidemiology, Biomarkers & Prevention
Table 3. Median nicotine (Mg/m3) concentrations in public places in major Latin American Cities
Guatemala
Costa Rica
Honduras
Panama
Mexico
Argentina*
Brazil
Chile
Paraguay
Peru
Uruguay*
Hospitals
Schools
Government building
<LD (<LD-0.010)
0.02 (0.01-0.04)
<LD (<LD-0.02)
<LD (<LD-<LD)
0.01 (0.004-0.02)
1.33 (0.51-3.12)
0.05 (0.02-0.09)
0.13 (0.03-0.47)
0.01 (0.001-0.03)
0.02 (0.01-0.07)
0.80 (0.31-1.69)
<LD (<LD-<LD)
<LD (<LD-<LD)
0.003 (<LD-0.005)
<LD (<LD-<LD)
<LD (<LD-<LD)
0.14 (0.05-0.23)
<LD (<LD-0.03)
0.01 (0.003-0.02)
0.001 (<LD-0.05)
0.01 (0.01-0.08)
0.08 (0.02-0.61)
0.012 (<LD-0.05)
0.02 (0.01-0.05)
0.05 (0.01-0.15)
<LD (<LD-0.004)
0.10 (0.04-0.14)
2.60 (1.43-2.99)
0.04 (0.03-0.21)
1.13 (0.08-0.13)
0.05 (0.03-0.10)
0.07 (0.01-0.31)
0.67 (0.47-0.94)
Airports
0.006
0.01
0.07
0.03
0.21
0.26
0.10
1.07
0.07
0.93
1.15
Restaurants
(<LD-0.01)
(0.01-0.03)
(0.02-0.59)
(0.01-0.69)
(0.04-0.50)
(0.18-0.67)
(0.03-0.16)
(0.64-1.07)
(0.05-0.20)
(0.20-1.30)
(0.74-2.49)
0.58
0.73
1.68
0.15
0.69
2.04
2.52
2.08
0.24
0.80
1.41
(0.46-0.71)
(0.46-1.80)
(0.35-2.29)
(0.01-2.10)
(0.52-0.86)
(0.90-2.60)
(1.25-3.95)
(1.08-3.56)
(0.06-0,36)
(0.15-2.42)
(0.41-2.48)
Bars
4.58
1.32
1.26
2.36
6.00
3.65
3.33
1.59
6.21
3.14
(1.71-6.45)
(0.75-7.43)
(0.77-1.77)
(2.14-2.88)
(3.85-8.60)
(3.58-3.65)
N/A
(2.06-4.82)
(0.78-6.68)
(4.00-9.12)
(0.77-4.82)
The cities were Guatemala City in Guatemala, Tegucigalpa in Honduras, Panama City in Panama, San Jose in Costa Rica, Mexico City in Mexico, Buenos
Aires in Argentina, Rio de Janeiro in Brazil, Santiago in Chile, Asuncion in Paraguay, Lima in Peru, and Montevideo in Uruguay. University concentrations
were not included because these institutions were not evaluated in the other Latin American cities.
Abbreviation: LD, limit of detection.
*Since the time of the survey, Uruguay has passed a smoke-free legislation that bans smoking in all public places including bars and restaurants. The city of
Buenos Aires has also passed a smoke-free legislation that covers many bars and restaurants.
a smoke-free university campus initiative recently
launched by the Pan American Health Organization,
nicotine was detected in more than half of the samples,
suggesting that the initiative needs to be better implemented and enforced. Compared with other workers,
workers in bars and restaurants are disproportionately
exposed to SHS in their workplace. Our results have the
strength to be highly sensitive and specific to assess SHS
exposure. Because tobacco smoke is the only source of
nicotine in the environment, confounding by other traces
of indoor air pollution (e.g., particulate matter from
diesel combustion) is not a concern (13).
As in other Latin American countries, nicotine concentrations were lower compared with those reported in
the 1990s in the United States (nicotine levels ranged
from 0.3 to 30 Ag/m3) or to current concentrations in most
European and Chinese cities (15-17). The lower smoking
prevalence and number of cigarettes smoked per day in
Latin America might explain these differences (2). Better
enforcement of the regulations available, particularly in
hospitals and schools, could also account for these lower
levels. In Guatemala, only bars yielded nicotine levels as
high as those documented in the United States prior to
the implementation of smoke-free environments or as
those currently documented in Europe (15, 16).
smoke-free (Table 4). Most workers agreed that tobacco
smoke harms others. Bar/restaurant workers were less
likely to agree that tobacco smoke harms others (57%).
Across sites surveyed, most workers did not agree that
smoking bans are unfair to smokers.
The odds of concurrence with the statements ‘‘workplaces should be smoke-free’’, ‘‘my institution should
be smoke-free’’, ‘‘tobacco smoke harms others’’, and ‘‘a
smoke ban is unfair to smokers’’ comparing respondents
in bars and restaurants to respondents in hospitals were
0.14 (0.05-0.43), 0.23 (0.08-0.65), 0.29 (0.09-0.92), and 2.68
(0.65-11.01), respectively. After multivariable adjustment
for smoking status, age, and sex, the corresponding odds
ratios were 0.14 (0.04-0.51), 0.25 (0.08-0.92), 0.19 (0.050.75), and 2.88 (0.60-13.85), respectively.
Discussion
In Guatemala, as in other Latin American countries,
nicotine was detected in most places that were surveyed
and nonsmoking areas in bars and restaurants did not
effectively protect nonsmokers from exposure to SHS. In
hospitals and schools, the levels were very low,
undetectable in most samples. In the Universities, despite
Table 4. Percentage (95% confidence interval) of respondents that concur with attitudes about smoke-free
environments and SHS exposure (Guatemala City, Guatemala)
Workplaces
should be
smoke-free
Public place
Hospital (n = 28)
School/University (n = 36)
Government building (n = 20)
Airport (n = 18)
Bar/restaurant (n = 37)
Smoking status
Never (n = 88)
Former (n = 11)
Current* (n = 39)
75
67
50
39
30
(55-89)
(49-81)
(27-73)
(17-64)
(16-47)
63 (52-73)
64 (31-89)
28 (15-44)
My institution
should be
smoke-free
68
82
55
50
32
(48-84)
(65-93)
(32-77)
(26-74)
(18-50)
70 (59-80)
64 (31-89)
30 (17-47)
Tobacco smoke
harms others
85
91
85
89
57
(66-96)
(76-98)
(62-97)
(65-99)
(39-73)
82 (73-90)
91 (59-100)
70 (53-83)
Smoke ban unfair
to smokers
11 (2-29)
5 (0.7-20)
5 (0.1-25)
11 (1.4-35)
25 (12-42)
12 (6-21)
9 (0.2-41)
15 (6-31)
*Current smokers include daily and less than daily smokers.
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In the study questionnaire, the workers seemed to be
knowledgeable about the health effects of SHS, however,
the level of knowledge was lower compared with other
Latin American countries (18). Most important, support
for smoke-free environments was high among employees
of most institutions. When analyzed separately by
smoking status, in general, smokers were less likely to
support smoke-free environments and to be knowledgeable about the damage caused by tobacco smoke. Yet,
tobacco control advocates need to especially focus their
education efforts among bar and restaurant workers for
several reasons. Although exposure to SHS was highest in
bars and restaurants, workers in these venues were less
supportive of smoke-free environments and were less
knowledgeable about the health effects of exposure to
SHS. The lack of support of workers in bars and
restaurants for smoke-free environments could be a result
of the tobacco industry’s Courtesy of Choice program.
This program, that is well established in Guatemala,
works with bar and restaurant owners to install
expensive and ineffective ventilation systems to implement smoking and nonsmoking sections. The lower
knowledge among bar and restaurant workers of the
harmful effects of SHS compared with workers in other
settings is particularly preoccupying because workers in
bars and restaurants are continuously exposed to SHS.
Yet, as evidenced from the California tobacco control
program, as smoke-free laws are implemented, patronage and workers’ support for the law should increase
(19, 20). Therefore, restaurant/bar owners and workers’
support for smoke-free environments is likely to increase
if complete smoke-free legislation were approved.
Our results have several limitations. Sampling locations were selected on a convenience basis. Yet, the
objective of the study was to collect policy-relevant
monitoring data that could be used to document
exposure to SHS in key locations and to promote
smoke-free regulations in Guatemala. We followed the
same protocol used in other Latin American cities to
allow for comparability across countries. Although the
location characteristics evaluated, including smoking ban
signs, ventilation, and volume, did not seem to account
for differences in nicotine concentrations across institutions, the study protocol did not comprehensively assess
building characteristics as determinants of nicotine
concentrations. Finally, nicotine measurements were
made continuously and not during the time of occupancy
only. Consequently, our results tend to be underestimates of those occurring during the time of occupancy.
The tobacco industry has played a determinant role in
obstructing smoke-free legislation in Guatemala as in the
rest of Latin America. The Latin Project, organized by
Philip Morris and British American Tobacco in the early
1990s, sought to obstruct sound antitobacco legislation,
hire well-placed physicians to act as ‘‘third-person’’
spokesmen, and lobbied politicians (21, 22). Guatemala,
Costa Rica, Argentina, Brazil, Chile, Venezuela, and
Ecuador were included in the project. The most notable
case, thus far, of the industry’s interference with tobacco
legislation is Argentina, where in the early 1990s, tobacco
industry consultant, Dr. Carlos Alvarez, successfully
lobbied then President Carlos Menem to veto a strong
antitobacco law (21, 23).
Currently, Guatemala is fighting to pass Law 3309
which mandates smoke-free workplaces. The law has
been initially approved in the Congress Health Commission but it has been in Congress for almost 1 year
without having been voted on. Bars and restaurants
have to be included in the law as it is where most of
the exposure to passive smoking is happening. Previous experience in Uruguay shows that the quantification of exposure to SHS in public places can move
smoke-free legislations forward (2). The solution to
SHS exposure is simple and straightforward, smokefree environments.
Acknowledgments
Monitor shipment was done in collaboration with the Pan
American Health Organization. We thank Marisol Acuña
(Ministry of Health, Santiago, Chile), Marta Angueira (UATA,
Argentina), Adriana Blanco-Marquizo (Intendencia Municipal
de Montevideo, Uruguay), Carmen Barco (CEDRO, Peru), Vera
L. Colombo (INCA, Rio de Janeiro, Brazil), Graciela Gamarra
(Ministry of Health, Paraguay), Claudia D. Gómez (IHADFA,
Tegucigalpa, Honduras), Katya Jiménez-Reyes (IAFA, San Jose,
Costa Rica), Reina Roa (Ministry of Health, Panamá), Raydel
Valdés (Instituto Nacional de Salud Pública, Mexico), and
Alfonso Zavaleta (CEDRO, Peru) for their contribution to the
data from other Latin American countries.
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